GW1--04526_Well Construction - GW1_20230713

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WELL CONSTRUCTION RECORD For Internal Use ONLY:
This form can be used for single or multiple wells
1.Well Contractor Information:
Kolby Mitchell Sawyers FRO ' `kTO � DESCRIPTION :: .
'
Well Contractor Name ft. ft. '
4471-A ft. ft.
NC Well Contractor Certification Number 15al1lTEf1'+Ci SiNaifot` iiilf casediifiils)AlttlNgRTif:applrcah[e)`:t
FROM TO DIAMETER THICKNESS MATERIAL
CLYDE SAWYERS & SON WELL & PUMP INC +1 ft. 50 ft. 6.25 ' in' #21 Pvc
Company Name ,.16,INNER CASING OR,TUBING(gtpthermatelbsed-loop);`:` <:'.
MCM-235W FROM '10 DIAMETER THICKNESS MATERIAI.
2.Well Construction Permit#: ft. ft. , in.
List all applicable well permits(i.e.County,State,Variance,Injection,etc.)
ft. ft. in.
3.Well Use(check well use): 17.SGREEhLr.,,.:
Water Supply Well: FROM TO DIAMETER SLOT SIZE THICKNESS MATERIAL
❑Agricultural ❑Municipal/Public ft. ft. in. ,
❑Geothermal(Heating/Cooling Supply) BResidential Water Supply(single) ft. ft. in.
❑Industrial/Commercial ❑Residential Water Supply(shared) �'E8 t1RAC1T...
FROM TO MATERIAL F.MPLACEMF.NT METHOD&AMOUNT
❑irrigation 0 ft• 20 ft- Bentonite Pumped
Non-Water Supply Well:
ft. ft. Cap Top with Bentonite Chips
❑Monitoring ❑Recovery
Injection Well: ft. ft.
❑Aquifer Recharge ❑Groundwater Remediation :191iSANDICRAVELRACK(ifappliicable) ,.W: _._`�X.s ._._.-_ ... Mi_x.
FROM TO MATERIAL EMPLACEMENT METHOD
❑Aquifer Storage and Recovery ❑Salinity Barrier ft. ft.
❑Aquifer Test ❑Stotmwater Drainage
ft. ft.
❑Experimental Technology El Subsidence Control
-.20:DRILt tr1 :TOG'(attac ardditiartatsheets ifateeessarv), .MMa=MKM
❑Geothermal(Closed Loop) ❑Tracer FROM TO DESCRIPTION(color,hardness,soil/rock type.grain size.etc.)
❑Geothermal(Heating/Cooling Return) ❑Other(explain under#21 Remarks) 0 ft. 50 ft. OVER BURDEN
5-18-2023 50 ft.ft. 405 ft. GRANITE
4.Date Well(s)Completed: Well ID# - ,
ft. r
5a.Well Location: .' °—''S...,.ii'c.' 4—`{
RONNIE&VICKY PUTNAM ft. ft. Ail I ., 2n23
Facility/Owner Name Facility ID#(if applicable) ft. ft.
ABBOTT ROAD CANTON, NC 28716 ft. ft. '":-. r-..'�n -..;,:q,:g tins
GI}t t zc`
Physical Address,City,and Zip
2411P+MAiRiC$.fit., _...:" ..,_...:....... .; _...::.._.iiMa..a
HAYWOOD 8666-31-8813 WELL WAS SELF CERTIFIED
County Parcel Identification No.(PIN)
5b.Latitude and Longitude in degrees/minutes/seconds or decimal degrees: 22.Certification:
(if well field,one lat/long is sufficient)
N 5-19-2023
' Signature of Certifi ell Contractor Date
6.is(are)the well(s): OPermanent or ❑Temporary By signing this form,I hereby certify that the wells)was(were)constructed in accordance
with 15A NCAC 02C.0100 or 15A NCAC 02C.0200 Well Construction Standards and that a
7.Is this a repair to an existing well: ❑Yes or ONo copy of this record has been provided to the well owner.
If this is a repair,fill out known we!!construction information and explain the nature of the
repair under#21 remarks section or on the back of this form. 23.Site diagram or additional well details:
You may use the back of this page to provide additional well site details or well
8.Number of wells constructed: ' construction details. You may also attach additional pages if necessary.
For multiple injection or non-water supply wells ONLY with the same construction,you can
submit one form. SUBMITTAL INSTUCTIONS
9.Total well depth below land surface:405 (ft.) 24a. For All Wells: Submit this form within 30 days of completion of well
For multiple wells list all depths if different(example-30 00'and 2(4100') construction to the following:
Division of Water Resources,Information Processing Unit,
10.Static water level below top of casing: 80 (ft)
.If water level is above casing.use"+•' 1617 Mail Service Center,Raleigh,NC 27699-1617
11.Borehole diameter: 6.25 (in.) 24b.For Infection Wells ONLY: In addition to sending the form to the address in
ROTARY 24a above, also submit a copy of this form within 30 days of completion of well
12.Well construction method: construction to the following:
(i.e.auger,rotary,cable,direct push,etc.)
Division of Water Resources,;Underground Injection Control Program,
FOR WATER SUPPLY WELLS ONLY: 1636 Mail Service Center,Raleigh,NC 27699-1636
3 RIG 24c.For Water Supply&Injection Wells:
13a.Yield(gpm) Method of test:
Also submit one copy of this form within 30 days of completion of
13b.Disinfection type: PILLS Amount: 35 well construction to the county health department of the county where
constructed. i 1
Form OW-1 North Carolina Department of Environment and Natural Resources-Division of Water Resources Revised August 2013